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Vernet Machado Bressan Wilke M, Iop GD, Faqueti L, Lemos da Silva LA, Kubaski F, Poswar FO, Michelin-Tirelli K, Randon D, Borelli WV, Giugliani R, Schwartz IVD. A Brazilian Rare-Disease Center's Experience with Glucosylsphingosine (lyso-Gb1) in Patients with Gaucher Disease: Exploring a Novel Correlation with IgG Levels in Plasma and a Biomarker Measurement in CSF. Int J Mol Sci 2024; 25:2870. [PMID: 38474117 PMCID: PMC10931658 DOI: 10.3390/ijms25052870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Gaucher disease (GD, OMIM 230800) is one of the most common lysosomal disorders, being caused by the deficient activity of the enzyme acid β-glucocerebrosidase (Gcase). Three clinical forms of Gaucher's disease (GD) are classified based on neurological involvement. Type 1 (GD1) is non-neuronopathic, while types 2 (GD2) and 3 (GD3) are neuronopathic forms. Gcase catalyzes the conversion of glucosylceramide (GlcCer) into ceramide and glucose. As GlcCer accumulates in lysosomal macrophages, it undergoes deacylation to become glycosylsphingosine (lyso-Gb1), which has shown to be a useful and reliable biomarker for the diagnosis and monitoring of treated and untreated patients with GD. Multiple myeloma (MM) is one of the leading causes of cancer-related death among patients with GD and monoclonal gammopathy of undetermined significance (MGUS) is a non-neoplastic condition that can be a telltale sign of a B clonal proliferation caused by the chronic activation of B cells. This study aimed to quantify Lyso-Gb1 levels in dried blood spots (DBS) and cerebrospinal fluid (CSF) as biomarkers for Gaucher disease (GD) and discuss the association of this biomarker with other clinical parameters. This is a mixed-methods study incorporating both cross-sectional and longitudinal elements within a cohort design with a convenience-sampling strategy. Data collection took place from January 2012 to March 2023. Lyso-Gb1 extraction from DBS involved the use of a methanol-acetonitrile-water mixture, followed by incubation and centrifugation. Analysis was performed using UPLC-MS/MS with MassLynx software version 4.2 and the control group for the DBS measurements included general newborns. CSF Lyso-Gb1 was extracted using ethyl acetate, analyzed by UPLC-MS/MS with a calibration curve, and expressed in pmol/L. Lysosomal activity in CSF was assessed by measuring chitotriosidase (Cht), and other lysosomal enzyme activities were assessed as previously described in the literature. Patients with metachromatic leukodystrophy (MLD) were used as controls. Thirty-two treated patients (twenty-nine GD1 and three GD3, all on ERT except for one GD type on SRT with eliglustat) and three untreated patients (one GD1, one GD2, and one GD3) were included. When analyzing only the treated GD1 group, a significant correlation was found between lyso-Gb1 and age (rho = -0.447, p = 0.001), ChT, and IgG levels (rho = 0.73, p < 0.001; and rho = 0.36, p = 0.03, respectively). Five GD1 patients (three females, mean age 40 years) also had their CSF collected and analyzed. The average measurement of lyso-Gb1 in CSF was 94 pmol/L (range: 57.1-157.9 pmol/L) versus <6.2 pmol/L in the control group (MLD). This is the first time, to the best of our knowledge, that lyso-Gb1 has been associated with IgG levels. While this finding reflects a risk for MGUS or MM and not only chronic plasma B-cell activation, it still requires further studies. Moreover, the analysis of CSF lyso-Gb1 levels in GD1 patients was demonstrated to be significantly higher than the control group. This raises the hypothesis that CSF lyso-Gb1 may serve as a valuable indicator for neurological involvement in GD, providing insights into the potential implications for neurological manifestations in GD, including GD1. The correlation between lyso-Gb1 and ChT levels in treated GD1 patients further underscores the interconnectedness of lysosomal markers and their relevance in monitoring.
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Affiliation(s)
| | - Gabrielle Dineck Iop
- Biodiscovery Laboratory, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035903, Brazil; (G.D.I.); (L.F.); (L.A.L.d.S.)
| | - Larissa Faqueti
- Biodiscovery Laboratory, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035903, Brazil; (G.D.I.); (L.F.); (L.A.L.d.S.)
| | - Layzon Antonio Lemos da Silva
- Biodiscovery Laboratory, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035903, Brazil; (G.D.I.); (L.F.); (L.A.L.d.S.)
| | - Francyne Kubaski
- Biochemical Genetics Laboratory, Greenwood Genetics Center, Greenwood, SC 29646, USA;
| | - Fabiano O. Poswar
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035003, Brazil;
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre 90035003, Brazil
| | - Kristiane Michelin-Tirelli
- LEIM-Biochemical Genetics Laboratory, Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035003, Brazil;
| | - Dévora Randon
- BRAIN Laboratory, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035003, Brazil
| | | | - Roberto Giugliani
- Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre 90035003, Brazil; (M.V.M.B.W.); (R.G.)
- Biodiscovery Laboratory, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035903, Brazil; (G.D.I.); (L.F.); (L.A.L.d.S.)
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035003, Brazil;
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre 90035003, Brazil
- Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre 90035003, Brazil
- Dasa Genômica, São Paulo 04078013, Brazil
- Casa dos Raros, Porto Alegre 90035003, Brazil
| | - Ida Vanessa D. Schwartz
- Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre 90035003, Brazil; (M.V.M.B.W.); (R.G.)
- Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035003, Brazil;
- BRAIN Laboratory, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035003, Brazil
- Department of Genetics, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre 90035003, Brazil
- Instituto Nacional de Doenças Raras—InRaras, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035003, Brazil
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Revel-Vilk S, Zimran A, Istaiti M, Azani L, Shalev V, Chodick G, Manor O, Paltiel O. Cancer Risk in Patients with Gaucher Disease Using Real-World Data. J Clin Med 2023; 12:7707. [PMID: 38137776 PMCID: PMC10744109 DOI: 10.3390/jcm12247707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
The association between GD and cancer has been uncertain due to ascertainment bias in previously published studies. We analyzed cancer incidence using the Maccabi Healthcare Service (MHS) electronic health records among 264 patients with GD compared to 3440 matched controls. We ascertained cancers diagnosed before and after the index date (i.e., the first documentation of GD in cases and the corresponding date for controls). Before the index date, cancers were diagnosed in 18 individuals, with 11 (4.2%) in the GD group and 7 (0.2%) in the control group. After the index date, cancers were diagnosed in 57 individuals, with 20 (7.9%) in the GD group and 37 (1.1%) in the control group, with a median follow-up of almost 13 years in both groups. The most common cancers diagnosed in GD were non-melanoma skin cancer (NMSC) and hematological malignancies, with a clustering of diagnoses around the time of GD diagnosis. The incidence of cancers (excluding MNSC) was 4.1 (95% CI 2.2-7.1) and 0.7 (95% CI 0.4-0.9) per 1000 patient-years in the GD and control groups, respectively, with an incidence rate ratio of 6.37 (95% CI 3-12.7). Patients with GD underwent more cancer screening tests than their counterparts in the control group. While our study revealed an increased occurrence of cancers in patients with GD, this finding might be partly attributed to the more rigorous surveillance procedures employed in this patient population.
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Affiliation(s)
- Shoshana Revel-Vilk
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel; (A.Z.); (M.I.)
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem, Jerusalem 9112102, Israel;
- Braun School of Public Health and Community Medicine, Hebrew University, Jerusalem 9112102, Israel;
| | - Ari Zimran
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel; (A.Z.); (M.I.)
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem, Jerusalem 9112102, Israel;
| | - Majdolen Istaiti
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel; (A.Z.); (M.I.)
| | - Liat Azani
- MaccabiTech, Maccabi Healthcare Services, Tel Aviv 6772168, Israel
| | - Varda Shalev
- School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel (G.C.)
| | - Gabriel Chodick
- School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel (G.C.)
| | - Orly Manor
- Braun School of Public Health and Community Medicine, Hebrew University, Jerusalem 9112102, Israel;
| | - Ora Paltiel
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem, Jerusalem 9112102, Israel;
- Braun School of Public Health and Community Medicine, Hebrew University, Jerusalem 9112102, Israel;
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Giuffrida G, Markovic U, Condorelli A, Duminuco A, Calafiore V, Conticello C, Romano A, Grasso S, Riccobene C, Ragusa MTV, Esposito B, Nicolosi D, Calagna M, Nardo A, Consoli U, Uccello G, Di Giacomo V, Neri S, Cingari MR, Rodà F, Innao V, Fiumara A, Duro G, Zizzo C, Di Raimondo F. Gaucher disease prevalence in 600 patients affected by monoclonal gammopathy of undetermined significance. Eur J Haematol 2023; 111:922-929. [PMID: 37747757 DOI: 10.1111/ejh.14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Gaucher disease (GD) is a rare autosomal recessive inherited disorder caused by the lysosomal enzyme acid β-glucosidase deficiency. Many patients experience a critical delay in the diagnosis of up to 8-10 years due to its rarity and variability in signs and symptoms, with the consultation of several specialists. PATIENTS AND METHODS This prospective observational study analyzed the prevalence of GD in 600 patients with monoclonal gammopathy of uncertain significance (MGUS) from January 2018 until February 2022. RESULTS The mean age of participants was 66 years, with a mean monoclonal component of 0.58 g/dL. In 433 MGUS patients with available data, anemia (hemoglobin level < 10 g/dL) was present in 31 patients (7%), and thrombocytopenia (platelet count <100.000/mm3 ) in 24 (5.5%). Of 600 MGUS patients tested for acid β-glucosidase enzyme activity, 7 patients (1.2%) had activity below 2.5 nmol/h/mL. In comparison, GBA gene analysis was executed in 110 patients. It revealed 4 patients (0.7%) affected by GD (3 patients with compound heterozygous mutation and 1 with homozygous mutation), with a prevalence of 1 every 150 MGUS patients. Furthermore, 12 out of the remaining 106 evaluated patients (11%) were carriers of a single heterozygous mutation while having regular enzyme activity. CONCLUSIONS The clinical heterogeneity of GD and frequent lack of awareness among physicians often lead to diagnostic delays and severe clinical manifestations. The role of MGUS in the presence of at least one clinical sign, such as low platelet count, organomegaly, bone pain, or bleeding tendency, could aid in initiating GD screening with DBS, thus reducing the period between symptom onset and the diagnosis of this rare disease.
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Affiliation(s)
- Gaetano Giuffrida
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Uros Markovic
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Annalisa Condorelli
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Andrea Duminuco
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Valeria Calafiore
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Concetta Conticello
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Alessandra Romano
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
- Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Stephanie Grasso
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Carla Riccobene
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | | | - Benedetta Esposito
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Daniela Nicolosi
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Marianna Calagna
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Antonella Nardo
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
- Postgraduate School of Hematology, University of Catania, Catania, Italy
| | - Ugo Consoli
- Unità Operativa Complessa (UOC) di Ematologia, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi, Catania, Italy
| | - Giuseppina Uccello
- Unità Operativa Complessa (UOC) di Ematologia, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi, Catania, Italy
| | | | - Santo Neri
- UOC di Ematologia, Azienda Ospedaliera Papardo, Messina, Italy
| | - Maria Rocca Cingari
- Unità Operativa Semplice Dipartimentale Ematologia, Ospedale San Vincenzo, Taormina, Italy
| | - Filippo Rodà
- Hemato-Oncology and Radiotherapy Department, Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Vanessa Innao
- Unità Operativa Complessa (UOC) di Ematologia, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi, Catania, Italy
| | - Agata Fiumara
- Regional Referral Centre for Metabolic Diseases, Pediatric Clinic, Department of Clinical and Experimental Medicine, University of Catania, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Giovanni Duro
- Institute for Biomedical Research and Innovation (IRIB-CNR), National Research Council of Italy, Palermo, Italy
| | - Carmela Zizzo
- Institute for Biomedical Research and Innovation (IRIB-CNR), National Research Council of Italy, Palermo, Italy
| | - Francesco Di Raimondo
- Division of Hematology, AOU Policlinico "G. Rodolico-San Marco", Catania, Italy
- Postgraduate School of Hematology, University of Catania, Catania, Italy
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Dinur T, Bauer P, Beetz C, Cozma C, Becker-Cohen M, Istaiti M, Rolfs A, Skrahina V, Zimran A, Revel-Vilk S. Contribution of Glucosylsphingosine (Lyso-Gb1) to Treatment Decisions in Patients with Gaucher Disease. Int J Mol Sci 2023; 24:ijms24043945. [PMID: 36835356 PMCID: PMC9966520 DOI: 10.3390/ijms24043945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/10/2023] [Accepted: 02/11/2023] [Indexed: 02/18/2023] Open
Abstract
Glucosylsphingosine (lyso-Gb1), the deacylated form of glucocerebroside, was shown to be the most specific and sensitive biomarker for diagnosing Gaucher disease (GD). The aim of this study is to assess the contribution of lyso-Gb1 at the time of diagnosis for treatment decisions in naïve patients with GD. Newly diagnosed patients from July 2014 to November 2022 were included in this retrospective cohort study. The diagnosis was done by sending a dry blood spot (DBS) sample for GBA1 molecular sequencing and lyso-Gb1 quantification. Treatment decisions were based on symptoms, signs, and routine laboratory tests. We diagnosed 97 patients (41 males), both type 1 (n = 87), and neuronopathic (n = 10). The median (range) age at diagnosis was 22 (1-78), with 36 children. In 65 patients, GD-specific therapy was started with a median (range) lyso-Gb1, 337 (60-1340) ng/mL, significantly higher than in patients who did not go on to treatment, 153.5 (9-442) ng/mL. Using a receiver operating characteristic (ROC) analysis, a cutoff of lyso-Gb1 > 250 ng/mL was associated with treatment with a sensitivity of 71% and specificity of 87.5%. Predictors of treatment were thrombocytopenia, anemia, and elevated lyso-Gb1 (>250 ng/mL). In conclusion, lyso-Gb1 levels contribute to the medical decision related to the initiation of treatment, mainly among mildly affected newly diagnosed patients. For patients with a severe phenotype, as for all patients, the main value of lyso-Gb1 would be to monitor response to therapy. The variable methodology and differences in the units of lyso-Gb1 measurements between laboratories prevent the adaptation of the exact cut-off we found in general practice. However, the concept is that a significant elevation, i.e., a several-fold increase from the diagnostic lyso-Gb1 cutoff, is related to a more severe phenotype and, accordingly, to the decision regarding the initiation of GD-specific therapy.
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Affiliation(s)
- Tama Dinur
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | | | | | | | | | - Majdolen Istaiti
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Arndt Rolfs
- Centogene GmbH, 18055 Rostock, Germany
- Medical Faculty, University of Rostock, 18051 Rostock, Germany
- Arcensus GmbH, 18055 Rostock, Germany
| | - Volha Skrahina
- Centogene GmbH, 18055 Rostock, Germany
- Arcensus GmbH, 18055 Rostock, Germany
| | - Ari Zimran
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel
| | - Shoshana Revel-Vilk
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112002, Israel
- Correspondence: ; Tel.: +972-2-655-5673; Fax: +972-2-651-7979
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5
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Rosenbloom BE, Cappellini MD, Weinreb NJ, Dragosky M, Revel‐Vilk S, Batista JL, Sekulic D, Mistry PK. Cancer risk and gammopathies in 2123 adults with Gaucher disease type 1 in the International Gaucher Group Gaucher Registry. Am J Hematol 2022; 97:1337-1347. [PMID: 36054609 PMCID: PMC9541044 DOI: 10.1002/ajh.26675] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 01/24/2023]
Abstract
There are numerous reports of cancers in Gaucher disease (GD) from mostly small single-center studies; however, precise risk estimates and cancer types involved have not been delineated. We conducted a study involving 2123 patients with GD type 1 (GD1) to assess the incidence of hematological malignancies, gammopathies, and solid tumors in an international observational study, the International Cooperative Gaucher Group Gaucher Registry (Clinicaltrials.gov: NCT00358943). Risk for cancer overall and for each type of malignancy was compared to the United States (US) population using the Surveillance, Epidemiology, and End Results database. Natural history of gammopathy was determined through assessing the progression from a diagnosis of monoclonal gammopathy of unknown significance (MGUS) to multiple myeloma (MM). Risk for hematological malignancies was more than four times higher than expected compared to the general population: non-Hodgkin lymphoma was approximately three times higher; MM was approximately nine times higher. Age-specific incidence rates of MGUS were unexpectedly high among younger patients. The 10-year cumulative incidence of MM after diagnosis of MGUS was 7.9%, comparable to the general population. Compared to the general US population, GD1 patients were at higher risk for solid malignancies of liver (2.9 times), kidney (2.8 times), melanoma (2.5 times), and breast (1.4 times). Colorectal, prostate, and lung cancer risks were lower than expected. These findings help advance care of patients with GD1 by supporting recommendations for individualized monitoring for malignancies and antecedents such as MGUS for MM and provoke important questions of the role of glucosylceramide and related sphingolipids in cancer biology.
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Affiliation(s)
| | - Maria Domenica Cappellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico MilanoMilanItaly
- Department of Internal MedicineUniversity of MilanMilanItaly
| | - Neal J. Weinreb
- Division of Hematology, Department of Internal MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
- Division of Clinical Genetics, Department of Human GeneticsUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Marta Dragosky
- Department of HematologyHenry Moore InstituteBuenos AiresArgentina
| | - Shoshana Revel‐Vilk
- Department of Pediatric Hematology, School of MedicineHebrew UniversityJerusalemIsrael
- Gaucher Unit, Shaare Zedek Medical CenterJerusalemIsrael
| | - Julie L. Batista
- Department of Epidemiology and BiostatisticsSanofiCambridgeMassachusettsUSA
| | - Davorka Sekulic
- Global Medical Affairs Hematology, Sanofi, CambridgeMassachusettsUSA
| | - Pramod K. Mistry
- Department of Internal MedicineYale University School of MedicineNew HavenConnecticutUSA
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Harel R, Gavish I, Aviv A, Greenman Maravi N, Trougouboff P, Zimran A, Revel-Vilk S. Enzyme replacement therapy leading to improvement in myeloma indices in a patient with concomitant Gaucher disease. Intern Med J 2022; 52:872-875. [PMID: 35538014 DOI: 10.1111/imj.15781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/11/2021] [Accepted: 12/11/2021] [Indexed: 11/29/2022]
Abstract
Patients with Gaucher disease (GD) have been shown previously to carry an increased risk for cancer, most commonly multiple myeloma (MM). It is currently unknown whether treatment for GD has an effect on the prevention or amelioration of MM. We present the case of a 41-year-old patient simultaneously diagnosed with GD and smouldering MM. Enzyme replacement therapy with Velaglucerase-alfa significantly improved myeloma indices.
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Affiliation(s)
- Reut Harel
- Haematology Department, Emek Medical Center, Afula, Israel
| | - Israel Gavish
- Haematology Department, Emek Medical Center, Afula, Israel
| | - Ariel Aviv
- Haematology Department, Emek Medical Center, Afula, Israel
| | | | | | - Ari Zimran
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shoshana Revel-Vilk
- Gaucher Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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7
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Chen F, Guo S, Li X, Liu S, Wang L, Zhang VW, Xu H, Huang Z, Ying Y, Shu S. Case Report: Be Aware of “New” Features of Niemann–Pick Disease: Insights From Two Pediatric Cases. Front Genet 2022; 13:845246. [PMID: 35360843 PMCID: PMC8961870 DOI: 10.3389/fgene.2022.845246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/15/2022] [Indexed: 11/14/2022] Open
Abstract
Niemann–Pick disease is a relatively common lysosomal storage disease. Cholestatic liver disease is a typical clinical phenotype of Niemann–Pick disease in infancy. The diagnosis is traditionally based on Niemann–Pick cells in bone marrow smears or liver biopsies. Treatment for cholestatic liver disease mainly includes ursodeoxycholic acid and liver protection drugs. Here, we reported two cases of Niemann–Pick disease type C, diagnosed by genetic analysis during early infancy. Besides cholestatic jaundice, the two patients also exhibited signs of immune system hyperactivity, such as elevated immunoglobulins or multiple autoantibodies, which might require the application of glucocorticoids. In addition, three novel missense variants of the NPC1 gene were identified. The findings suggest that immune activation should be considered as a “new” clinical phenotype of lysosomal storage diseases.
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Affiliation(s)
- Fan Chen
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shan Guo
- Department of Gastroenterology, Wuhan Children’s Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuesong Li
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shengxuan Liu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Wang
- AmCare Genomics Lab, Guangzhou, China
| | | | - Hui Xu
- Department of Pathology, School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhihua Huang
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanqin Ying
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Yanqin Ying, ; Sainan Shu,
| | - Sainan Shu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Yanqin Ying, ; Sainan Shu,
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8
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Capp JP, Bataille R. A bone paradigm challenging the standard model of myeloma oncogenesis. Crit Rev Oncol Hematol 2022; 172:103640. [PMID: 35183697 DOI: 10.1016/j.critrevonc.2022.103640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 02/02/2022] [Accepted: 02/16/2022] [Indexed: 11/25/2022] Open
Abstract
The standard model of multiple myeloma (MM) oncogenesis from monoclonal gammopathy of undetermined significance (MGUS) relies on genetic instability in the normal counterparts of MM cells. However, the importance of both MGUS-associated and MM-induced bone changes has been recently re-appraised, emphasizing the bone microenvironment (BME) as a tissue of significance. In this review, we propose that early BME alterations (bone senescence and inflammation, i.e. bone inflamm'aging) at the pre-MGUS stage could be causal, and not simply permissive, and creative of phenotypic instability and genetic alterations thanks to the concept of tissue disruption-induced cell stochasticity (TiDiS). This article offers a bone scenario challenging the chromosome-and-gene-centric standard model of MM oncogenesis. The high incidence of both MGUS and MM in Gaucher disease supports such a scenario.
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Affiliation(s)
- Jean-Pascal Capp
- Toulouse Biotechnology Institute, INSA/University of Toulouse, CNRS, INRAE, 135, avenue de Rangueil, 31077 Toulouse, cedex 04, France.
| | - Régis Bataille
- University of Angers, School of Medecine, rue Haute de Reculée, 49045 Angers, cedex 01, France
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9
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Portier E, Talbot A, Nguyen Y, Royer B, Pettazzoni M, Ben Salah I, Trichet C, Vercellino L, Arnulf B, Belmatoug N. Multiple myeloma occurring in a case of Niemann-Pick disease Type B: A pathophysiological link? Br J Haematol 2022; 197:e53-e55. [PMID: 35141883 DOI: 10.1111/bjh.18050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/05/2022] [Accepted: 01/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Elodie Portier
- Department of Internal Medicine, Referral Centre of Lysosomal Diseases, APHP-Nord, Beaujon Hospital, University of Paris, Clichy, France
| | - Alexis Talbot
- Department of Immuno-Hematology, APHP, Saint Louis Hospital, University of Paris, Paris, France
| | - Yann Nguyen
- Department of Internal Medicine, Referral Centre of Lysosomal Diseases, APHP-Nord, Beaujon Hospital, University of Paris, Clichy, France
| | - Bruno Royer
- Department of Immuno-Hematology, APHP, Saint Louis Hospital, University of Paris, Paris, France
| | - Magali Pettazzoni
- Biochemical and Molecular Biology Department, UF Maladies Héréditaires du Métabolisme, Hospices Civils de Lyon, Bron, France
| | - Imen Ben Salah
- Laboratory of Hematology and Hemostasis, APHP-Nord, Beaujon Hospital, University of Paris, Clichy, France
| | - Catherine Trichet
- Laboratory of Hematology and Hemostasis, APHP-Nord, Beaujon Hospital, University of Paris, Clichy, France
| | - Laetitia Vercellino
- Department of Nuclear Medicine, APHP, Saint-Louis Hospital, University of Paris, Paris, France
| | - Bertrand Arnulf
- Department of Immuno-Hematology, APHP, Saint Louis Hospital, University of Paris, Paris, France
| | - Nadia Belmatoug
- Department of Internal Medicine, Referral Centre of Lysosomal Diseases, APHP-Nord, Beaujon Hospital, University of Paris, Clichy, France
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10
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Cabrera-Reyes F, Parra-Ruiz C, Yuseff MI, Zanlungo S. Alterations in Lysosome Homeostasis in Lipid-Related Disorders: Impact on Metabolic Tissues and Immune Cells. Front Cell Dev Biol 2021; 9:790568. [PMID: 34957117 PMCID: PMC8703004 DOI: 10.3389/fcell.2021.790568] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/22/2021] [Indexed: 12/16/2022] Open
Abstract
Lipid-related disorders, which primarily affect metabolic tissues, including adipose tissue and the liver are associated with alterations in lysosome homeostasis. Obesity is one of the more prevalent diseases, which results in energy imbalance within metabolic tissues and lysosome dysfunction. Less frequent diseases include Niemann-Pick type C (NPC) and Gaucher diseases, both of which are known as Lysosomal Storage Diseases (LSDs), where lysosomal dysfunction within metabolic tissues remains to be fully characterized. Adipocytes and hepatocytes share common pathways involved in the lysosome-autophagic axis, which are regulated by the function of cathepsins and CD36, an immuno-metabolic receptor and display alterations in lipid diseases, and thereby impacting metabolic functions. In addition to intrinsic defects observed in metabolic tissues, cells of the immune system, such as B cells can infiltrate adipose and liver tissues, during metabolic imbalance favoring inflammation. Moreover, B cells rely on lysosomes to promote the processing and presentation of extracellular antigens and thus could also present lysosome dysfunction, consequently affecting such functions. On the other hand, growing evidence suggests that cells accumulating lipids display defective inter-organelle membrane contact sites (MCSs) established by lysosomes and other compartments, which contribute to metabolic dysfunctions at the cellular level. Overall, in this review we will discuss recent findings addressing common mechanisms that are involved in lysosome dysregulation in adipocytes and hepatocytes during obesity, NPC, and Gaucher diseases. We will discuss whether these mechanisms may modulate the function of B cells and how inter-organelle contacts, emerging as relevant cellular mechanisms in the control of lipid homeostasis, have an impact on these diseases.
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Affiliation(s)
- Fernanda Cabrera-Reyes
- Department of Cellular and Molecular Biology, Faculty of Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Gastroenterology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Parra-Ruiz
- Department of Cellular and Molecular Biology, Faculty of Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Gastroenterology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - María Isabel Yuseff
- Department of Cellular and Molecular Biology, Faculty of Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Silvana Zanlungo
- Department of Gastroenterology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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11
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Durán A, Rebolledo-Jaramillo B, Olguin V, Rojas-Herrera M, Las Heras M, Calderón JF, Zanlungo S, Priestman DA, Platt FM, Klein AD. Identification of genetic modifiers of murine hepatic β-glucocerebrosidase activity. Biochem Biophys Rep 2021; 28:101105. [PMID: 34458595 PMCID: PMC8379285 DOI: 10.1016/j.bbrep.2021.101105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/18/2022] Open
Abstract
The acid β-glucocerebrosidase (GCase) enzyme cleaves glucosylceramide into glucose and ceramide. Loss of function variants in the gene encoding for GCase can lead to Gaucher disease and Parkinson's disease. Therapeutic strategies aimed at increasing GCase activity by targeting a modulating factor are attractive and poorly explored. To identify genetic modifiers, we measured hepatic GCase activity in 27 inbred mouse strains. A genome-wide association study (GWAS) using GCase activity as a trait identified several candidate modifier genes, including Dmrtc2 and Arhgef1 (p=2.1x10−7), and Grik5 (p=2.1x10−7). Bayesian integration of the gene mapping with transcriptomics was used to build integrative networks. The analysis uncovered additional candidate GCase regulators, highlighting modules of the acute phase response (p=1.01x10−8), acute inflammatory response (p=1.01x10−8), fatty acid beta-oxidation (p=7.43x10−5), among others. Our study revealed previously unknown candidate modulators of GCase activity, which may facilitate the design of therapies for diseases with GCase dysfunction. Hepatic GCase activity significantly differs among mouse strains. Genome-wide association study revealed putative modifier genes of GCase activity. Bayesian integration of multi-omics identified a regulatory network of GCase activity. This study may facilitate the design of therapies for diseases with GCase dysfunction.
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Affiliation(s)
- Anyelo Durán
- Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Boris Rebolledo-Jaramillo
- Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Valeria Olguin
- Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Marcelo Rojas-Herrera
- Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Macarena Las Heras
- Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Juan F Calderón
- Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Silvana Zanlungo
- Department of Gastroenterology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - David A Priestman
- Department of Pharmacology, University of Oxford, Oxford, OX1 3QT, UK
| | - Frances M Platt
- Department of Pharmacology, University of Oxford, Oxford, OX1 3QT, UK
| | - Andrés D Klein
- Centro de Genética y Genómica, Facultad de Medicina, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
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12
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Revel-Vilk S, Szer J, Zimran A. Hematological manifestations and complications of Gaucher disease. Expert Rev Hematol 2021; 14:347-354. [PMID: 33759681 DOI: 10.1080/17474086.2021.1908120] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Gaucher disease (GD), although pan-ethnic and rare (common in Ashkenazi Jews), is of great importance to hematologists both for diagnosis and management. The need for increased awareness of GD is that delayed diagnosis may lead to preventable irreversible complications (mainly skeletal) or unnecessary invasive procedures (e.g. bone marrow biopsy), and the birth of another affected sibling due to lack of genetic consulting.Areas covered: The review outlines the common hematological manifestations of GD, including splenomegaly, thrombocytopenia, and anemia. Other hematological manifestations such as coagulation abnormalities, platelet dysfunction, gammopathy, and other hematological malignancies associated with GD are also discussed. Current and future treatment modalities are delineated, including enzyme replacement and substrate reduction therapy, pharmacological chaperon, and gene therapy. A literature search was conducted to identify original research articles relevant to hematology manifestations and GD published before November 2020.Expert opinion: Patients with GD should be ideally followed and treated in a center of excellence where the GD expert benefits from experienced consultants in relevant disciplines. Due to the availability of several very expensive treatment options, it is important to have an unbiased expert who can select the most suitable management for the individual patients (including withholding prescription in asymptomatic patients).
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Affiliation(s)
- Shoshana Revel-Vilk
- Gaucher Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jeff Szer
- Clinical Haematology at Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - Ari Zimran
- Gaucher Unit, Shaare Zedek Medical Centre, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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13
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Zimran A, Ruchlemer R, Revel-Vilk S. A patient with Gaucher disease and plasma cell dyscrasia: bidirectional impact. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:389-394. [PMID: 33275748 PMCID: PMC7727517 DOI: 10.1182/hematology.2020000123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Patients with Gaucher disease (GD), a rare autosomal recessive glycosphingolipid storage disease, commonly present to hematologists with unexplained splenomegaly, thrombocytopenia, anemia, and bone symptoms. Patients with GD may develop other manifestations, such as autoimmune thrombocytopenia, monoclonal gammopathy, multiple myeloma, or, even more rarely, other hematological malignancies; sometimes they are first diagnosed during an assessment of those disorders. Although the diagnosis and management of patients with GD have significantly evolved over the last 30 years, some patients remain poor responders to GD-specific therapy, needing novel and investigational therapies. Ideally, patients with GD, like patients with other rare diseases, should be managed by a multidisciplinary team expert with the diverse clinical manifestations and potential GD-related or -unrelated comorbidities. The hematology community should be knowledgeable regarding the presentation and the variety of hematologic complications and comorbidities associated with Gaucher disease.
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Affiliation(s)
- Ari Zimran
- Gaucher Unit
- School of Medicine, Hebrew University, Jerusalem, Israel
| | - Rosa Ruchlemer
- Department of Hematology, Shaare Zedek Medical Center, and
- School of Medicine, Hebrew University, Jerusalem, Israel
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14
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Andrade-Campos MM, de Frutos LL, Cebolla JJ, Serrano-Gonzalo I, Medrano-Engay B, Roca-Espiau M, Gomez-Barrera B, Pérez-Heredia J, Iniguez D, Giraldo P. Identification of risk features for complication in Gaucher's disease patients: a machine learning analysis of the Spanish registry of Gaucher disease. Orphanet J Rare Dis 2020; 15:256. [PMID: 32962737 PMCID: PMC7507684 DOI: 10.1186/s13023-020-01520-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/24/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Since enzyme replacement therapy for Gaucher disease (MIM#230800) has become available, both awareness of and the natural history of the disease have changed. However, there remain unmet needs such as the identification of patients at risk of developing bone crisis during therapy and late complications such as cancer or parkinsonism. The Spanish Gaucher Disease Registry has worked since 1993 to compile demographic, clinical, genetic, analytical, imaging and follow-up data from more than 400 patients. The aims of this study were to discover correlations between patients' characteristics at diagnosis and to identify risk features for the development of late complications; for this a machine learning approach involving correlation networks and decision trees analyses was applied. RESULTS A total of 358 patients, 340 type 1 Gaucher disease and 18 type 3 cases were selected. 18% were splenectomyzed and 39% had advanced bone disease. 81% of cases carried heterozygous genotype. 47% of them were diagnosed before the year 2000. Mean age at diagnosis and therapy were 28 and 31.5 years old (y.o.) respectively. 4% developed monoclonal gammopathy undetermined significance or Parkinson Disease, 6% cancer, and 10% died before this study. Previous splenectomy correlates with the development of skeletal complications and severe bone disease (p = 0.005); serum levels of IgA, delayed age at start therapy (> 9.5 y.o. since diagnosis) also correlates with severe bone disease at diagnosis and with the incidence of bone crisis during therapy. High IgG (> 1750 mg/dL) levels and age over 60 y.o. at diagnosis were found to be related with the development of cancer. When modelling the decision tree, patients with a delayed diagnosis and therapy were the most severe and with higher risk of complications. CONCLUSIONS Our work confirms previous observations, highlights the importance of early diagnosis and therapy and identifies new risk features such as high IgA and IgG levels for long-term complications.
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Affiliation(s)
- Marcio M Andrade-Campos
- Grupo Español de Enfermedades de Depósito Lisosomal, Sociedad Española de Hematología y Hemoterapia, (GEEDL), Zaragoza, Spain
- Hospital del Mar Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona, Spain
- Fundación Española para el Estudio y Terapéutica de la Enfermedad de Gaucher y otras lisosomales (FEETEG), Zaragoza, Spain
| | - Laura López de Frutos
- Grupo Español de Enfermedades de Depósito Lisosomal, Sociedad Española de Hematología y Hemoterapia, (GEEDL), Zaragoza, Spain
- Fundación Española para el Estudio y Terapéutica de la Enfermedad de Gaucher y otras lisosomales (FEETEG), Zaragoza, Spain
- Grupo de Investigación en Enfermedades Metabólicas y Hematológicas Raras (GIIS-012), Instituto Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Jorge J Cebolla
- Grupo de Investigación en Enfermedades Metabólicas y Hematológicas Raras (GIIS-012), Instituto Investigación Sanitaria Aragón, Zaragoza, Spain
- Departamento de Bioquímica, Biología Molecular y Celular, Universidad de Zaragoza, Zaragoza, Spain
| | - Irene Serrano-Gonzalo
- Fundación Española para el Estudio y Terapéutica de la Enfermedad de Gaucher y otras lisosomales (FEETEG), Zaragoza, Spain
- Grupo de Investigación en Enfermedades Metabólicas y Hematológicas Raras (GIIS-012), Instituto Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Blanca Medrano-Engay
- Fundación Española para el Estudio y Terapéutica de la Enfermedad de Gaucher y otras lisosomales (FEETEG), Zaragoza, Spain
- Grupo de Investigación en Enfermedades Metabólicas y Hematológicas Raras (GIIS-012), Instituto Investigación Sanitaria Aragón, Zaragoza, Spain
| | - Mercedes Roca-Espiau
- Fundación Española para el Estudio y Terapéutica de la Enfermedad de Gaucher y otras lisosomales (FEETEG), Zaragoza, Spain
- Centro de Imagen. Vivo, Zaragoza, Spain
| | | | - Jorge Pérez-Heredia
- Instituto de Biocomputación y Física de Sistemas Complejos (BIFI), Zaragoza, Spain
| | - David Iniguez
- Kampal Solutions, Universidad de Zaragoza, Zaragoza, Spain
- Instituto de Biocomputación y Física de Sistemas Complejos (BIFI), Zaragoza, Spain
| | - Pilar Giraldo
- Grupo Español de Enfermedades de Depósito Lisosomal, Sociedad Española de Hematología y Hemoterapia, (GEEDL), Zaragoza, Spain.
- Fundación Española para el Estudio y Terapéutica de la Enfermedad de Gaucher y otras lisosomales (FEETEG), Zaragoza, Spain.
- Grupo de Investigación en Enfermedades Metabólicas y Hematológicas Raras (GIIS-012), Instituto Investigación Sanitaria Aragón, Zaragoza, Spain.
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